Total Laryngectomy - Indications, Contraindications, and Procedure

Introduction

Laryngeal cancer occurs due to the formation of malignant (cancer) cells in the tissues of the larynx. As the malignancy increases, cancer cells invade tissues and cause damage to the body. The main aim of the treatment for laryngeal cancer is to control the disease. The secondary purposes are saving the functions of swallowing and speech and avoiding the procedure of tracheostomy (a procedure done to help breathe by creating an opening at the front of the neck). Total laryngectomy is done in advanced laryngeal malignancy or adjacent structure and in tumors that are potential for malignancy.

What Is Laryngeal Cancer?

The larynx is situated in the neck and helps in breathing, swallowing, and speaking. Laryngeal cancer is carcinoma of supraglottic, glottic, and subglottic structures (part of the larynx consisting of vocal cords and an opening between them). Squamous cell carcinoma is the most common cancer occurring. Primary laryngeal adenocarcinoma, chondrosarcoma, lymphoma, and plasmacytoma are also found to be commonly occurring malignancies of the larynx. It is generally seen among 65 years old individuals and above.

What Is a Total Laryngectomy?

A total laryngectomy is the complete removal of the larynx. It is a necessary procedure as treatment in

• Cancer of the larynx.

• Severe injury to the neck (gunshot wound).

• Damage to larynx stem because of radiation therapy.

Depending on the condition of the cancer, treatment options of partial (some part) or complete laryngectomy is opted for.

There are two pathways present in the throat. One to the stomach and one to the lungs. The esophagus is the pathway to the stomach and trachea (windpipe) and the larynx leads to the lungs. During breathing, the larynx opens to let air reach to lungs. During swallowing, the larynx rises and closes the airway to keep food and liquid from getting into the lungs. Vocal cords (muscular folds in the larynx) vibrate to speak with voice.

What Are the Indications of Total Laryngectomy?

Indications for total laryngectomy are

• Advanced laryngeal cancer or pharynx that is connected to the thyroid and soft tissue of the larynx.

• In case of failure of radiotherapy or chemotherapy (other treatment of cancer).

• Tumors that cannot be treated with conservative treatment.

• Some tumors are resistant to radiotherapy, like soft tissue sarcomas, melanomas, tumors of minor salivary glands, etc.

• Severe trauma to laryngeal structures that cannot be reconstructed.

• Individuals who do not have a voice and have aspirations for a long time due to paralysis of cranial nerves IX, X, XI.

• Increased risk of papillomatosis leads to recurrent laryngeal papillomatosis occurs.

What Are the Contraindications of Total Laryngectomy?

Contraindications of the total laryngectomy are

• Presence of tumors that are metastatic for long distances.

• The general condition of an individual is poor, which does not allow for anesthesia.

• Tumors that contain common or internal carotid artery.

• Tumors that affect parts of the tongue.

How to Get Ready for a Surgical Procedure Like a Total Laryngectomy?

Laryngectomy is a lengthy procedure that may take five to twelve hours and is performed under general anesthesia. Tests are done before surgery. Other specialists like speech therapists and swallowing specialists will help prepare the individual for a change of life after surgery.

The following should be done to get ready for the surgical procedure

• If any medications are being taken for some health issues, be informed to surgeons.

• If any supplements are being taken, be informed (herbs, vitamins, minerals, or any home remedies.

• If any heart devices (pacemaker-like devices) are installed in the body must be brought to the notice.

• If a condition like sleep apnea is present, be informed.

• If any problem with the anesthesia is present, be informed.

• If allergic to any medication.

• If not willing for a blood transfusion

• If any habits like the consumption of alcohol are present must be informed.

Description of possible complications to the individual.

• Bleeding.

• Infection.

• Anesthesia-complications.

• Damage to adjacent structures.

• Salivary fistula (an abnormal connection between two parts).

• Stomal stenosis (Stricture present in gastrointestinal tract).

• Swallowing difficulties.

• Hypothyroidism (low levels of thyroid hormone).

• Loss of smell sensation.

How Is a Total Laryngectomy Performed?

Steps to be followed during the procedure

• Incisions are made in the neck through which the larynx will be removed.

• Lymph nodes and part of the pharynx may be removed depending on the cause of the laryngectomy.

• Lymph nodes are part of the immune system (that helps fight infections) and are affected by cancer.

• A common space is a pharynx where nasal passages, mouth, upper esophagus, and larynx meet. Partial removal of the pharynx is usually done during the cancer treatment of the larynx, which is called a pharygectomy.

• A stoma (a permanent hole about the size of a nickel) is created by a doctor in front of the trachea. This stoma connects outside to the lungs for breathing.

• Some will have a tracheoesophageal puncture (TEP) performed among individuals who underwent laryngectomy. In TEP, a small hole is created in the trachea and esophagus. This procedure can be done at laryngectomy surgery or later. Something must remain in place within TEP so that it is kept open.

• After completion of the surgery, the throat muscles and skin of the neck will be closed with surgical stitches.

• Drainage tubes are placed in the neck to drain the fluids and blood for many days after the laryngectomy.

How Will the Recovery Just After the Surgery of the Larynx?

Following instructions and steps to be followed

• Individuals undergoing surgery are kept in the intensive care unit (ICU).

• The doctor will monitor for blood pressure (BP), breathing, and other vital signs.

• Individuals receive oxygen through a stoma after surgery.

• Till the throat heals, the patient is to be refrained from eating. A feeding tube is given between the nose and stomach, which helps in giving nutrition.

• Once the condition stabilizes, the individual is shifted to a regular hospital.

• During this time, healing continues, and the individual learns to swallow again and begins to learn to communicate without a larynx.

• The individual will be encouraged to move to prevent blood clots, decrease the risk of pneumonia, and help get accustomed to the stoma and new way of breathing.

• Individuals may be given physical therapy, speech therapy, and language therapy.

How to Take Care of Stoma?

• During recovery, it is essential to take care of the stoma after the laryngectomy. The opening may lead to infections due to bacteria and viruses in the body.

• Clean edges with gauze and mild soap and water.

• Remove excess mucus and crusting by using salt water spray. Crusting may disturb the airflow to the lungs.

• Coughing can help to remove mucus. If coughing cannot be done, suction is to be used to remove mucus.

• Humidified air helps to prevent the crusting of the stoma. Using a special mask helps deliver humidified air directly to the stoma.

How to Improve Speech After a Total Laryngectomy?

Speech can be improved with the use of many methods. It is difficult to make sounds without a larynx.

• Non-Verbal Communication: Non-verbal communication includes gestures, facial expressions, picture boards, or saying words without a voice. Writing by hand or computer is also a form of nonverbal communication.

• Esophageal Speech: An individual uses air from the mouth and traps it in the throat and upper esophagus. Controlled release of air causes vibrations, and speech can be performed using the mouth, lips, and tongue. This type of speech is difficult to learn but effective.

• Electrolarynx: A device used against the neck or adaptor for the mouth. It enhances the speech when an individual talk but sounds robotic. It may be used as a short-term or long-term solution.

• TEP Speech: In this, tracheoesophageal puncture is used. A valve is inserted through TEP. This valve allows air to enter the esophagus from the trachea. But materials from the esophagus (food and liquids) cannot enter the lungs. Devices are attached to voice prostheses which help to speak.

Conclusion

Larynx is an important part of breathing and speaking. Total laryngectomy makes individuals face problems and affects their quality of life. Learning to live without a larynx becomes difficult, scary, and frustrating. This can be done with the help of doctors’ suggestions and will power of an individual to learn newer techniques to improve the quality of lif